Liability Insurance Questionnaire
Public & Products Liability insurance is available for most business operations. This policy will provide protection to you, where you have a liability at law for property damage &/or bodily injury to another person.
In order for City Rural Insurance Brokers to provide you with an Obligation Free Quote, please complete the following.
Personal Details
First Name *
Surname *
Email Address *
Phone *
Fax
Mobile Phone
Preferred method of contact *
Business Details
Company Name
Trade Name
Proprietor Name
ABN
Taxable Percentage Claimed
Postal address
Suburb/Town *
State
Postcode *
Situation of premises/shop/offices (if same as above leave blank)
Address
Suburb/Town
State
Postcode
Period of Insurance
Cover can only commence once full payment and completed application have been received and approved
From Date (Note: insurance starts 4pm)
To Date (Note: insurance ends 4pm)
Limit of Indemnity Required * -
Please describe principal art form:
Description artistic and art related business activities undertaken:
Relevant Credentials (Diploma/Degree/Dip Ed etc)
Other Details
Estimated number per annum of
Public exhibitions
Workshops
Estimated number of attendees
Per exhibition
All exhibitions
Type of exhibition
Estimated number of attendees
Per workshop
All workshops
Type of workshop
Do you engage Sub-Contractors and/or Service Providers?
Number of Tutors/Entertainers
Number of Other Staff
Turnover (last 12 mths)
Turnover (estimated for next 12 mths)
Are there any hazardous activities associated with your business?
Construction of the premises:
Walls
Floors
Roof
No. of Storeys
Age of Building
Fire Protection and Security Details
Contractual Liability
Coverage for Liability assumed under agreement or contract will be limited to lease liability or liability assumed under a warranty of fitness or quality as regards your products.
Do you assume Liability under contract or hold others harmless (other than lease liability)?
General Details
Have you or anyone this policy is to cover (in the past 5 years)
1. Made any claim(s) on an insurer for loss or damage?
2. Had any insurance declined or cancelled, proposal/application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer?
3. Suffered any loss or damage which would have been covered by the proposed insurance policy?
4. Have you or any partner(s) or director(s) of the business ever been declared bankrupt?
5. Ever been involved in a company or business which became insolvent or subject to any form of insolvency or administration (e.g. liquidation or receivership)?
6. Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?
7. Been liable for any civil offence or pecuniary penalty (exceeding $5,000)?
Duty of Disclosure
In order to make an informed assessment of the risk and calculate the appropriate premium, your insurer needs information about the risk you are asking it to insure.
For this reason, before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 to disclose to your insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk and, if so, on what terms. The duty also applies when you renew, extend, vary or reinstate a contract of insurance.
You do not have to disclose anything that:
- Reduces the risk to be undertaken by the insurer;
- Is common knowledge;
- Your insurer knows, or in the ordinary course of its business, ought to know; or
- If the insurer has waived your obligation to disclose.
If you do not comply with your duty of disclosure, your insurer may be entitled to reduce its liability in respect of a claim or may cancel your contract of insurance. If the non-disclosure was fraudulent, the insurer may be able to avoid (or cancel) the contract of insurance from its beginning. This would have the effect that you were never insured.
One important matter to be disclosed is the history of losses suffered by the person seeking insurance or any closely associated person or entity. As you are responsible for checking that you have made complete disclosure, we suggest that you keep an up to date record of all such losses and claims.
I have read the Duty of Disclosure above. *
